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1. A nurse is providing dietary teaching for a client who has a burn injury and adheres to a vegan diet. The nurse should recommend which of the following foods as the best source of protein to promote wound healing?
- A. One cup of brown rice
- B. One cup of orange juice
- C. One cup of pureed avocado
- D. One cup of lentils
Correct answer: D
Rationale: Lentils are an excellent source of plant-based protein, essential for wound healing in a vegan diet. Brown rice, orange juice, and pureed avocado are not protein-rich foods like lentils and would not provide sufficient protein for wound healing in this scenario.
2. An advance directive known as a durable power of attorney involves appointing another person called a(n) _____ to act as the decision maker in the event of the patient's incapacitation.
- A. witness
- B. primary caregiver
- C. health care agent
- D. state proxy
Correct answer: C
Rationale: The correct answer is 'health care agent.' A health care agent is appointed through a durable power of attorney to make medical decisions on behalf of a patient who becomes incapacitated. The term 'witness' (choice A) is incorrect because a witness only observes the signing of the directive and does not make decisions. 'Primary caregiver' (choice B) is also incorrect as they may provide care but are not necessarily legally empowered to make decisions. 'State proxy' (choice D) is not commonly used in the context of advance directives or health care decision making, making it an incorrect choice.
3. What is the desirable resting systolic blood pressure for adults?
- A. <130 mmHg>
- B. <105 mmHg>
- C. <120 mmHg>
- D. <140 mmHg>
Correct answer: C
Rationale: The desirable resting systolic blood pressure for adults is less than 120 mmHg. This blood pressure is associated with a lower risk of cardiovascular disease. Measurements higher than 120 mmHg (choices A and D) indicate elevated blood pressure, which can lead to hypertension and other health complications if not managed. A reading of less than 105 mmHg (choice B) could indicate low blood pressure, which also poses health risks such as dizziness and fainting.
4. A guideline that is utilized in determining priorities is to assess the status of the following, EXCEPT:
- A. perfusion
- B. locomotion
- C. respiration
- D. mentation
Correct answer: D
Rationale: When determining priorities in patient care, assessing perfusion, respiration, and locomotion are crucial. However, assessing mentation is also important but not typically included in the ABCs of emergency care. Monitoring mentation is essential for neurological assessment and detecting changes in mental status, but it is not part of the immediate priorities in life-threatening situations.
5. Why is there an ethical dilemma?
- A. Because the law does not clearly state what is right from what is wrong
- B. Because morality is subjective and it differs from each individual
- C. Because the patient's right coincide with the nurse's responsibility
- D. Because the nurse lacks ethical knowledge to determine what action is correct and what action is unethical
Correct answer: C
Rationale: The correct answer is C because an ethical dilemma arises when the patient's rights conflict with the nurse's responsibilities, requiring a careful balance to ensure ethical care delivery. Choices A and B are incorrect because ethical dilemmas are not solely about legal or subjective moral issues. Choice D is incorrect as nurses are generally equipped with ethical knowledge through education and training, and ethical dilemmas are more about conflicting values and responsibilities rather than a lack of knowledge.
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